title: Management of delayed postoperative hemorrhage after pancreaticoduodenectomy: a meta-analysis.
abstract: OBJECTIVE
  To determine whether interventional radiology (IR) or laparotomy (LAP) is the best management of delayed postoperative hemorrhage (DPH) after pancreaticoduodenectomy. Data Source We undertook an electronic search of MEDLINE and selected for analysis only original articles published between January 1, 1990, and December 31, 2007.
  
  
  METHODS
  Two of us independently selected studies reporting on clinical presentation and incidence of postoperative DPH and the following outcomes: complete hemostasis, morbidity, and mortality.
  
  
  METHODS
  Two of us independently performed data extraction. Data were entered and analyzed by means of dedicated software from The Cochrane Collaboration. A random-effects meta-analytical technique was used for analysis.
  
  
  RESULTS
  One hundred sixty-three cases of DPH after pancreaticoduodenectomy were identified from the literature. The incidence of DPH after pancreaticoduodenectomy was 3.9%. Seventy-seven patients (47.2%) underwent LAP; 73 (44.8%), IR; and 13 (8%), conservative treatment. On meta-analysis comparing LAP vs IR for DPH, no significant difference was found between the 2 treatment options for complete hemostasis (73% vs 76%; P = .23), mortality (43% vs 20%; P = .14), or morbidity (77% vs 35%; P = .06).
  
  
  CONCLUSIONS
  This meta-analysis, although based on data from small case series, is unable to demonstrate any significant difference between LAP and IR in the management of DPH after pancreaticoduodenectomy. The management of this life-threatening complication is difficult, and the appropriate treatment pathway ultimately will be decided by the clinical status of the patient and the institution preference.
authors.affiliation: HPB Unit, Division of Surgery and Intensive Care, Imperial College School of Medicine, Hammersmith Hospital, Du Cane Road, London, England.
authors.forename: Paolo
authors.initials: P
authors.lastname: Limongelli
authors.forename: Shirin E
authors.initials: SE
authors.lastname: Khorsandi
authors.forename: Madhava
authors.initials: M
authors.lastname: Pai
authors.forename: James E
authors.initials: JE
authors.lastname: Jackson
authors.forename: Paul
authors.initials: P
authors.lastname: Tait
authors.forename: John
authors.initials: J
authors.lastname: Tierris
authors.forename: Nagy A
authors.initials: NA
authors.lastname: Habib
authors.forename: Robin C N
authors.initials: RC
authors.lastname: Williamson
authors.forename: Long R
authors.initials: LR
authors.lastname: Jiao
mesh_terms: D016001:Confidence Intervals; D005500:Follow-Up Studies; D006488:Hemostasis, Surgical / Q000379:methods* / Q000401:mortality; D006801:Humans; D010535:Laparoscopy / Q000379:methods / Q000401:mortality; D007813:Laparotomy / Q000379:methods* / Q000401:mortality; D016017:Odds Ratio; D010190:Pancreatic Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016577:Pancreaticoduodenectomy / Q000009:adverse effects* / Q000379:methods; D019106:Postoperative Hemorrhage / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D011336:Probability; D015642:Radiology, Interventional / Q000379:methods*; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome